HISTORY
Patient is a 57-year-old male who states Saturday morning he woke up kind of with a click in his neck. He took an aspirin. It persisted and he took one of his Voltaren which he had not taken in a while, but he took it about a month ago for his knee, took 3 or 4 days' worth and it worked, so he has just had them around, but he said later in the day, stomach kind of felt full. Sunday morning, did not feel that good. He had a bowl of raisin bran. He states throughout the day the stomach just kept somewhat tighter and full, like he just could not eat anymore and he was bloated. He has a history of gallstones, which he has not had removed. He turned down surgery and was just going to watch it. He is just very fearful of anesthesia, but he said he said this is unlike his gallbladder attacks as he has had 2 or 3 of those. He went riding around to gas up his car, just thinking that maybe getting up and moving around would help his stomach, kind of move everything. He went back home because he felt too bad. His wife went to the drugstore to get some Mylanta. She called him about 6 o'clock, he had been throwing up blood and he had dark stools that she states smelled real bad and just felt bad, and he just threw up a lot of blood. He presented to the emergency room with a GI bleed and was evaluated. In the ER, his abdomen was tender. He said they gave him some medication; looks like they gave him some fluids, Protonix, and Zofran and he said now he is pretty comfortable. He said after he threw up a bottle of blood and everything kind of broke loose, he felt better.
Patient is a 57-year-old male who states Saturday morning he woke up kind of with a click in his neck. He took an aspirin. It persisted and he took one of his Voltaren which he had not taken in a while, but he took it about a month ago for his knee, took 3 or 4 days' worth and it worked, so he has just had them around, but he said later in the day, stomach kind of felt full. Sunday morning, did not feel that good. He had a bowl of raisin bran. He states throughout the day the stomach just kept somewhat tighter and full, like he just could not eat anymore and he was bloated. He has a history of gallstones, which he has not had removed. He turned down surgery and was just going to watch it. He is just very fearful of anesthesia, but he said he said this is unlike his gallbladder attacks as he has had 2 or 3 of those. He went riding around to gas up his car, just thinking that maybe getting up and moving around would help his stomach, kind of move everything. He went back home because he felt too bad. His wife went to the drugstore to get some Mylanta. She called him about 6 o'clock, he had been throwing up blood and he had dark stools that she states smelled real bad and just felt bad, and he just threw up a lot of blood. He presented to the emergency room with a GI bleed and was evaluated. In the ER, his abdomen was tender. He said they gave him some medication; looks like they gave him some fluids, Protonix, and Zofran and he said now he is pretty comfortable. He said after he threw up a bottle of blood and everything kind of broke loose, he felt better.
PAST MEDICAL HISTORY
He has a history of esophageal ulcers. He also has a history of squamous cell carcinoma
of the lip in 1980. He has had
hypercalcemia in the past, but I think this is associated with alcohol which he
used to be a heavy drinker for the last 5 or 6 years, but he has been abstinent
for the last 13 months. He went off to
Life Recovery and he has done well.
ALLERGIES
He has no known allergies.
CURRENT MEDICATIONS
Include Zocor 40 milligrams a day. I gave him some Voltaren 40 tablets on the 28
of May, and he states maybe took them 3 or 4 days; he still has a bunch
left. He had a nuclear stress test in
January when he had one of his gallbladder attacks and it was normal.
FAMILY HISTORY
His mother deceased of small cell cancer of the lung and had
gallbladder disease. Dad is alive with
dementia. Sister also had her gallbladder
out.
SOCIAL HISTORY
He has been married for 20 years. He has 2 kids. He has a 30 pack-year history plus of
smoking. He has been abstinent for 13
months from alcohol. He owns a candy
shop.
OBJECTIVE
GENERAL: When I see
the patient, he is lying in bed sleeping.
He feels much more comfortable.
ENT EXAM: Basically
unremarkable. He has some ruddy changes
in his face which have been chronic.
CHEST: He has
bilateral breath sounds with minimal rhonchi.
CARDIAC: Revealed a
regular rate and rhythm.
ABDOMEN: He has
positive bowel sounds. He appears
slightly distended, but he says he does not feel full at all and he has good
bowel sounds now. Pushing on his upper
abdomen he is not hurting, suggested it just felt like a band across there, but
nothing like his gallbladder attacks.
RECTAL: In the ER was
positive, so this was not repeated and he had black melenic stools.
White count on admission was 21,700 with a left shift. H and H were 13.6 and 38.1. He has O positive blood. Amylase and lipase were normal. INR was 1.1.
His electrolytes plus came back down, except for BUN and
creatinine. His hemoglobin has ______
down to 11 and 31. This is probably a
total of about 2 units of blood.
ASSESSMENT
1. Gastrointestinal
bleed, definitely upper gastrointestinal bleed, possibly lower gastrointestinal
because it has started turning red in the lower part unless this is rapid
transit.
2. Hyperlipidemia,
on Zocor.
3. Cigarette
abuse.
4. Gallstones.
5. Past
history of heavy ethanol abuse, but it was for about 5 to 6 years, prior to
that he was a social drinker and very minimal, but he has been abstinent for 13
months.
PLAN
At this time, I am going to get H and H q.6 h. Consult ____________-. EGD is in order. We will also consider cholecystectomy while
he is here.
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